326 final exam
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing? A) Decreased mental status B) Elevated blood pressure C) Labored respirations D) Decreased urine output
A) Decreased mental status
Which findings by the nurse would suggest that a client with cirrhosis has developed hepatic encephalopathy? Select all that apply. A) Delirium B) Decreased serum albumin C) Increased serum ammonia D) Asterixis E) Serum sodium of 138 mEq/dL
A) Delirium C) Increased serum ammonia D) Asterixis
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: heart rate 117/min, respiratory rate 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this time? A) Administer oxygen therapy B) Obtain a spiral CT scan C) Notify the provider D) Administer heparin via IV infusion
A) Administer oxygen therapy
Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? A) "I need to take a laxative such as Milk of Magnesia if I don't have a bowel movement every day." B) "If my bowel pattern changes on its own, I should call you." C) "I need to stay hydrated." D) "Eating my meals at regular times is likely to result in regular bowel movements."
A) "I need to take a laxative such as Milk of Magnesia if I don't have a bowel movement every day."
A client newly diagnosed with type 1 diabetes mellitus tells the nurse that the diagnosis must be wrong because the client eats all of the time but never gains weight. Which response by the nurse is most appropriate? A) "You are eating large quantities because your condition makes it difficult for your body to obtain energy from the foods taken in." B) "Thin people can be diabetic, too." C) "Your condition makes it impossible for you to gain weight." D) "Your lab tests indicate the presence of diabetes."
A) "You are eating large quantities because your condition makes it difficult for your body to obtain energy from the foods taken in."
After a thyroidectomy, the client develops a positive Trousseau's sign. What medication does the nurse anticipate that the provider will order? A) Administer calcium gluconate B) Administer liothyronine therapy C) Administer potassium chloride D) Administer levothyroxine therapy
A) Administer calcium gluconate
What patient assessment findings by the nurse indicate pulmonary edema? Select all that apply. A) Difficulty breathing lying supine B) Anxiety C) Crackles in lung bases D) +2 Pedal pulses E) Pulse oximetry reading of 96%
A) Difficulty breathing lying supine B) Anxiety C) Crackles in lung bases
Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L Which action should the nurse take? A) Encourage the client to take deep, cleansing breaths B) Obtain a prescription for a diuretic C) Have the client breathe into a rebreather bag D) Request a prescription for the administration of sodium bicarbonate
A) Encourage the client to take deep, cleansing breaths
A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? A) Excessive mechanical ventilation B) Inadequate nutrition C) Prolonged gastric suction D) Airway obstruction
A) Excessive mechanical ventilation
The nurse is caring for a client with Graves disease. When observing the facial features of the client (pictured below), the nurse notes that the client is exhibiting which associated sign of the disease? A) Exophthalmos B) Conjunctivitis C) Periorbital edema D) Lacrimation
A) Exophthalmos
The nurse is providing care for a client admitted for an acute exacerbation of asthma. Which medication does the nurse anticipate administering to relieve the acute symptoms exhibited by the client? A) Inhaled short acting beta agonist B) Inhaled long acting beta agonist C) Oral corticosteroid D) Oral anticholinergic
A) Inhaled short acting beta agonist
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. The nurse assesses the client and determines they are hypovolemic. What is the next most appropriate nursing action? A) Notify the health care provider. B) Monitor the client. C) Medicate the client for nausea. D) Elevate the head of the bed.
A) Notify the health care provider.
A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply. A) Obtaining an accurate daily weight B) Weighing and recording all wet diapers C) Restricting fluids prior to weighing the child D) Changing breastfeedings to bottle-feedings E) Obtaining an accurate stool count
A) Obtaining an accurate daily weight B) Weighing and recording all wet diapers E) Obtaining an accurate stool count
The nurse is concerned that a client diagnosed with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data should indicate to the nurse that the client is not currently experiencing an alteration in perfusion? Select all that apply. A) Peripheral pulses present and full B) Poor skin turgor C) Oriented to person, place, and time D) Capillary refill of nail beds 3 seconds E) Bowel sounds sluggish in all four quadrants
A) Peripheral pulses present and full C) Oriented to person, place, and time D) Capillary refill of nail beds 3 seconds
A disorder in which endocrine gland could result in an increase in growth of the bones, organs, and muscles? A) Pituitary gland B) Parathyroid glands C) Thyroid gland D) Adrenal glands
A) Pituitary gland
Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? A) Potassium of 6.3 mEq/L B) Sodium of 147 mEq/L C) Calcium of 9.5 mg/dL D) Magnesium of 1.9 mEq/L
A) Potassium of 6.3 mEq/L
The nurse is providing care to an adult client with a history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax (punctured lung). Which interventions are appropriate for this client? Select all that apply A) Prepare for chest tube insertion B) Administer 8 liters of oxygen per minute by nasal cannula C) Administer prescribed antihypertensive medication D) Administer intravenous caffeine per order E) Elevate head of bed
A) Prepare for chest tube insertion E) Elevate head of bed
The nurse is reviewing a patients complete blood count (CBC) following the administration of 2 units packed red blood cells. The nurse anticipates which values will have changed as a a result of that administration: A) RBC Count B) WBC Count C) Hct D) Platelets E) Hgb
A) RBC Count C) Hct E) Hgb
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome? Select all that apply. A) Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. B) Use the smallest gauge IV when obtaining IV access C) Apply gentle pressure for the shortest possible time period after performing venipuncture. D) Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. E) Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food.
A) Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. D) Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. E) Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food.
A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? A) loss of 2.2 lb (1 kg) in 24 hours B) blood pH of 7.25 C) serum sodium level of 135 mEq/L D) serum potassium level of 3.5 mEq/L
A) loss of 2.2 lb (1 kg) in 24 hours
A client with heart failure has an Ejection Fraction (EF) of 40%. (to best answer this question, look up "ejection fraction" or review HF case study answer key after posted). Which assessment finding best represents this diagnostic? A) Decreased heart rate B) Dyspnea at rest C) Shortness of breath with activity D) Clear lung sounds
B) Dyspnea at rest
A nurse is preparing to administer the medication atropine to a patient. Which assessment findings would make the nurse question whether this medication is safe to give? (Select all that apply): A) Loose watery stools B) Hard, dry stools C) Tachycardia D) Mild abdominal cramping E) Hypoactive bowel tones
B) Hard, dry stools C) Tachycardia E) Hypoactive bowel tones
A school nurse is teaching a 12-year-old child with recently diagnosed type 1 diabetes about the action of insulin injections. What statement indicates that the child understands how insulin works in the body? A) "It keeps glucose from being stored in the liver." B) "Glucose is carried into cells, where it is used for energy." C) "It stops wasting of blood glucose by converting it to glycogen." D) "Glucose is released as fats break down."
B) "Glucose is carried into cells, where it is used for energy."
A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? A) "If my skin becomes dry and itchy I can apply extra lotion." B) "I should drink more water when I feel thirsty or becoming irritable" C) "Vitamin hydration drinks would be good when I feel my heart pounding and become lightheaded." D) "Dehydration is only a problem in the summer months when it's hot outside."
B) "I should drink more water when I feel thirsty or becoming irritable"
The nurse determines that additional discharge teaching is needed when the patient with chronic heart failure says: A) "I plan to organize my household tasks so I don't have to constantly go up and down the stairs." B) "I should weigh myself every morning and go on a diet if I gain 2-3 lbs." C) "I should hold my digoxin and call the doctor if I experience nausea and vomiting." D) "I will take my pulse every day and call the clinic if it is irregular or less than 50."
B) "I should weigh myself every morning and go on a diet if I gain 2-3 lbs."
A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breaths/min, serum potassium of 2.9 mEq/L and arterial blood gas indicating metabolic alkalosis. The nurse should implement which prescription first? A) Repeat laboratory work in 4 hours B) 5% Dextrose in 0.45% normal saline with KCL 40 mEq/L at 125 mL/h C) Oxygen at 4L per nasal cannula D) 12-lead ECG
B) 5% Dextrose in 0.45% normal saline with KCL 40 mEq/L at 125 mL/h
The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize their secretions? A) Frequent and aggressive nasopharyngeal suctioning B) Augmented coughing or huff coughing C) Application of oxygen at 4LPM per NC D) Positioning the patient side-lying on his left side
B) Augmented coughing or huff coughing
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds them very difficult to arouse. Which of the following findings best explains these changes? A) Low hematocrit and high urine specific gravity. B) Below normal serum glucose and elevated serum ammonia levels. C) Below normal clotting factors and platelet count. D) Elevated liver enzymes and low serum protein level.
B) Below normal serum glucose and elevated serum ammonia levels.
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment is the most objective indicator of the client's fluid and electrolyte balance? A) Client statement "I've been drinking lots of water" B) Blood labs C) Intake and output results D) Skin turgor
B) Blood labs
pulse oximetry monitor indicates that the patient has a drop in SpO2 from 95% to 85% over several hours. RR is 18 and the patient is watching TV. The first action the nurse should take is to: A) Order stat ABGs to confirm SpO2 B) Check the position of the probe on the patient's finger C) Notify the health care provider D) Start O2 administration by nasal cannula at 2L minute
B) Check the position of the probe on the patient's finger
A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun peritoneal dialysis. Which information about diet will the nurse include in patient teaching? A) More protein is allowed because urea and creatinine are removed by dialysis. B) Dietary potassium is not restricted because the level is normalized by dialysis. C) Unlimited fluids are allowed because retained fluid is removed during dialysis. D) Increased calories are needed because glucose is lost during hemodialysis.
B) Dietary potassium is not restricted because the level is normalized by dialysis.
The nurse is caring for a patient who is admitted with an opioid overdose. The patient is somnolent with BP 90/60, apical pulse 110, and respiratory rate 8. Based upon the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? A) Hypoxemic respiratory failure related to diffusion limitation B) Hypercapnic respiratory failure related to alveolar hypoventilation C) Hypercapnic respiratory failure related to increased airway resistance D) Hypoxemic respiratory failure related to shunting of blood
B) Hypercapnic respiratory failure related to alveolar hypoventilation
It is determined that a client has dysfunction of the pituitary gland due to a traumatic brain injury (TBI). The client is experiencing over-secretion of antidiuretc hormone (ADH). What assessment data would the nurse expect to see? A) Hyperkalemia B) Hypokalemia C) High urine specific gravity D) Hypernatremia E) Hyponatremia
B) Hypokalemia C) High urine specific gravity E) Hyponatremia
A patient has pulmonary fibrosis, a thickening of the alveolar-capillary membrane. They experience hypoxemia during exercise but not at rest. To plan for the patient's care, the nurse should know that exercise is causing which physiologic mechanism of impaired gas exchange? A) Exercise induced alveolar hypoventilation B) Increased blood movement shortens gas exchange C) Exercise induced ventilation failure D) Alveolar shunt due to pulmonary fibrosis
B) Increased blood movement shortens gas exchange
The nurse is caring for an infant who has a 3-day history of diarrhea and is admitted to the pediatric unit. The nurse obtains the infant's vital signs, performs a physical assessment, and reviews the infant's arterial blood gas results. Which acid-base imbalance does the nurse suspect? Vital Signs: Rectal temp 99.4 F (37.4 C) Apical pulse 155 RR 40 breaths/min ABG results: pH 7.30 PCO2 35mmHg HCO3- 17 mEQ/L Physical Assessment: Lethargic, irritable Dry skin and mucous membranes Inelastic tissue turgor Dark amber urine A) Respiratory Acidosis B) Metabolic Acidosis C) Metabolic Alkalosis D) Respiratory Alkalosis
B) Metabolic Acidosis
A client with hypothyroidism who experiences trauma, emergency surgery, or severe infection is at risk for developing which of the following conditions? A) Thyroid storm B) Myxedema coma C) Hepatitis B D) Malignant hyperthermia
B) Myxedema coma
When caring for a client with a newly diagnosed cardiac dysrhythmia, which laboratory value is the priority for the nurse to monitor? A) Sodium of 130 mEq/L B) Potassium of 3.1 mEq/L C) Calcium of 8.6 mEq/L D) Hematocrit of 40%
B) Potassium of 3.1 mEq/L
A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? A) Increases cardiac conduction B) Slows and strengthens cardiac contractions C) Reduces edema D) Increases rate of ventricular contractions
B) Slows and strengthens cardiac contractions
Which of the following nursing actions is the priority for a patient experiencing a potential transfusion reaction? A) Re-type and crossmatch B) Stop the transfusion C) Administer epinephrine D) Apply oxygen
B) Stop the transfusion
A nurse administers albuterol to a child with asthma. What side effect will the nurse monitor the child? A) Flushing B) Tachycardia C) Dyspnea D) Hypotension
B) Tachycardia
A client is experiencing parathyroid dysfunction. Which serum calcium concentration in the client would support the diagnosis? A) 10.2 mg/dL B) 9.7 mg/dL C) 7.8 mg/dL D) 8.9 mg/dL
C) 7.8 mg/dL
A client has been diagnosed with cirrhosis. When obtaining a health history, the nurse should specifically determine if the client takes which of the following? A) Levothyroxine B) Polyethylene Glycol C) Acetaminophen D) Spironolactone
C) Acetaminophen
A nurse is monitoring a client at risk of developing respiratory failure. The nurse recognizes a common early clinical manifestation of respiratory failure when the client develops which of the following symptoms? A) Cyanosis and retractions B) Hypotension and tachycardia C) Dyspnea and tachypnea D) Respiratory distress and frothy sputum
C) Dyspnea and tachypnea
Which acid-base imbalance is caused by chronic renal failure, loss of bicarbonate during severe diarrhea, or metabolic disorders that result in overproduction of lactic acid? A) Metabolic alkalosis B) Respiratory acidosis C) Metabolic acidosis D) Respiratory alkalosis
C) Metabolic acidosis
The client who has an acute kidney injury has an elevated blood urea nitrogen (BUN). What is the likely cause of this finding? A) Below-normal metabolic rate B) Fluid retention C) Reduced renal blood flow D) Hemolysis of red blood cells
C) Reduced renal blood flow
A 3-year-old with dehydration has vomited three times in the last hour and continues to have frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. They have a normal saline lock in their right hand, and have had less than adequate urine output in the last 4 hours. The nurse calls the health care provider with the recommendation for which prescription? A) Establishing an indwelling catheter B) Beginning an IV antibiotic C) Starting a fluid bolus of normal saline D) Giving a dose of an antidiarrheal
C) Starting a fluid bolus of normal saline
Which assessment data best indicates the client with type 1 diabetes is adhering to the medical treatment regimen? A) The client's fasting blood glucose is 100 mg/dL. B) The client's urine specimen has no ketones. C) The client's glycosylated hemoglobin is 5.8%. D) The client's glucometer reading is 120 mg/dL.
C) The client's glycosylated hemoglobin is 5.8%.
The nurse is reviewing the laboratory reports of a group of older adult clients. Which client sodium lab value demonstrates an age-related impairment in thirst mechanism? A) 140 mEq/L B) 145 mEq/L C) 134 mEq/L D) 167 mEq/L
D) 167 mEq/L
A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (a loop diuretic) and digoxin. What does the nurse determine is the most likely cause of the depletion? A) Inadequate oral fluid intake B) Continuous dyspnea C) Sodium restriction D) Diuretic therapy
D) Diuretic therapy
The major goal of nursing care for a client with heart failure and pulmonary edema is to: A) Decrease peripheral edema B) Enhance comfort C) Get accurate daily weights D) Increase cardiac output
D) Increase cardiac output
A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? A) Limiting the drugs' combination effects B) Correcting the associated dehydration C) Preventing increased sodium levels D) Maintaining potassium levels
D) Maintaining potassium levels